A. Chapter
Contents

This chapter contains the following topics:

Topic

1701.00    Review Prior Requesting a Hearing

1702.00    Hearing Process Timeframes

1703.00    Actions That May Be Appealed

1704.00    Customer's Hearing Rights

1705.00    Office of Administrative Hearings Responsibility

1706.00    Office of Administrative Legal Services Responsibility

1707.00    Program Support Eligibility Hearing Coordinator Responsibility

1708.00    Eligibility Office Responsibility

1709.00    Filing an Eligibility Hearing Request

1710.00    The Eligibility Hearing Request Date

1711.00    Routing of the Hearing Request

1712.00    Review the Reason for the Hearing Request

1713.00    Timeliness of Hearing Request

1714.00    Continuing Eligibility

1715.00    Restoring the Level of Covered Services

1716.00    Restoring the Prior Level of Covered Services

1717.00    How to Prepare a Hearing Packet

1718.00    Pre-Hearing Discussion

1719.00    Voluntary Withdrawal of Hearing Request

1720.00    Changes in Eligibility or SOC Before a Hearing Decision

1721.00    Eligibility Hearing

1722.00    Hearing Decision

1723.00    Petition for Rehearing

1724.00    Appeals to Superior Court

1725.00    Disability Reconsideration Requests

1726.00    Grievances

Appendix 17A Letter to Complainant-No Hearing Scheduled

Appendix 17B OAH Information Pamphlet

Appendix 17C Request for Continuance Form

Appendix 17D Request for Witness/Party to Appear Telephonically

B. Introduction

The eligibility hearing is an administrative process designed to ensure a fair and impartial review of an adverse action that is appealed. Adverse action is any action taken to deny or discontinue eligibility, a delay in an eligibility determination, an increase in the share of cost, or a reduction in services. A customer is entitled to a hearing for any adverse action resulting from eligibility decisions. 

This chapter provides you with information related to the eligibility hearings process.

A. Request for Review

The customer may request a discussion before filing a formal request for hearing. Follow all procedures for the Pre-Hearing Discussion (MS 1118) except it is not necessary to obtain a voluntary withdrawal if the customer agrees with the action.

B. What to do if the Action is not Understood or Reversed

If the action is not understood or reversed, advise the customer of:

• The right to request a hearing;

• The method for requesting a hearing; and

• The timeliness requirements for requesting a hearing.

Help the customer complete the request for hearing if the customer asks for help.

A. Timeframes

Listed below are the maximum timeframes for the hearing process. However, the processing may conclude sooner because the timeframes for completing some actions depends on when the previous action is completed.

Day

From the Date the

Action

1

N/A

Hearing request received by the eligibility office or the Office of Administrative Legal Services (OALS).

5

Eligibility office receives the hearing request directly from the customer or Program Support receives the request for file from OALS

Eligibility office sends at least a minimum hearing packet (MS 1717). Continue eligibility if appropriate (MS 1714).

Note: The due date is on the fax cover sheet sent by Program Support.

15

Eligibility office receives the hearing request

Eligibility office holds a Pre-Hearing Discussion, if possible. If not possible, hold on a later date.

20

Eligibility office receives the hearing request

Eligibility office sends voluntary withdrawal or a maximum hearing packet (MS 1717).

25

Hearing request is received

The Office of Administrative Legal Services issues a Notice of Hearing that includes the hearing date, issue to be addressed, legal authorities, and hearing rights.

20

Hearing is held

The Administrative Law Judge (ALJ) issues a recommended decision to the AHCCCS Director.

30

ALJ makes a recommended decision. However, must be within 90 days from the date the hearing request is received, or 120 days if a continuance is requested and granted

The AHCCCS Director issues a Director's Decision.

30

Director issues a Decision or 35 days if the Director's Decision is mailed

The complainant or Administration may file a motion for rehearing.

30

Director issues a Decision or 35 days if the Director's Decision is mailed

The complainant may appeal to Superior Court. It is not necessary for the complainant to request a rehearing before appealing to Superior Court.

A. Actions That May be Appealed

A customer has the right to an eligibility hearing when an Eligibility Specialist:

• Approves Medicare Cost Sharing under SLMB, QI-1, or QI-2 rather than QMB;

• Approves ALTCS acute care rather than ALTCS;

• Denies eligibility for ALTCS, SSI/MAO, or Medicare Cost Sharing;

• Discontinues or temporarily suspends eligibility for ALTCS, SSI/MAO, or Medicare Cost Sharing;

• Delays the eligibility decision beyond the 45^th or 90^th day processing timeframe when necessary information has been provided;

• Establishes or increases the share of cost amount;

• Reduces services from Long Term Care to Transitional and the customer has to move to an HCBS living arrangement; from ALTCS Long Term Care to ALTCS Acute Care; from ALTCS Long Term Care to AHCCCS Medical Services or Medicare Cost Sharing; from AHCCCS Medical Services (SSI/MAO) to Medicare Cost Sharing; or, from one Medicare Cost Sharing group to another that provides fewer benefits;

• Denies eligibility on a community spouse case due to resources and the customer or spouse disagrees with the amount of the Community Spouse Resource Deduction (CSRD); or

• Establishes a share of cost on a community spouse case and the customer or the customer's spouse disagrees with the amount of the Community Spouse Monthly Income Allowance (CSMIA) 

Note: If a DDSA is completed by the AHCCCS staff and DDSA determines that the customer is not disabled, the customer has the right to an eligibility hearing based on DDSA's decision. See MS 1725 for special procedures for disability reconsideration requests.

B. Actions That May Not be Appealed

The customer is not entitled to a hearing when the adverse action results from an automatic change that is required by Federal or State law, such as change in the Federal Benefit Rate or the Federal Poverty Limit. 

If an adverse action is one that does not affect the customer's eligibility or share of cost, the customer is not entitled to a hearing but may file a grievance as described at MS 1726.

Note: Program Support or OALS will notify you if the action cannot be appealed. OALS will notify the complainant.

C. Notice of an Action That Can be Appealed

AHCCCS has the responsibility to provide written notice to the customer when an action that can be appealed is taken. The notice must include:

• The name of the customer(s) affected by the action;

• A description of the action that is being taken;

• The effective date of the denial, discontinuance, reduction in covered services, or share of cost increase;

• The reasons for the action including income calculations and the income limit when the reason is based on excess income and/or resource calculation and the resource limit when the reason is based on excess resources;

• The legal authority supporting the action;

• Where the references are located for review; and

• If eligibility is discontinued or the share of cost is increased, an explanation of the customer's right to continued eligibility or to continue paying the lower share of cost amount pending the hearing decision, and the process to do so.

A. Customer's Hearing Rights

The person who files a hearing request is called a complainant. When a hearing request is received, inform the complainant of the right to:

• Review, obtain, or copy any portion of the case record necessary for proper presentation of the case (see MS 1600 for release of information guidelines);

• Examine all documents to be used by the state at the hearing;

• Bring legal counsel, a relative, friend, other spokesman or witnesses to the hearing;

• Establish all pertinent facts and circumstances;

• Present an argument without undue interference;

• Question or refute any testimony or evidence including the opportunity to confront or cross-examine adverse witnesses;

• Ask OAH to furnish an interpreter if the complainant does not speak English or is hearing or speech impaired; and

• Ask OAH to make an accommodation for special needs.

Note: This information is normally provided during the Pre-Hearing Discussion (MS 1718). If you are not conducting a Pre-Hearing Discussion, send the Hearing Rights Information (DE-154) form to the complainant for review and signature.

The Director's Decision notifies the complainant of the right to:

• Petition for a rehearing (MS 1723); and/or

• Appeal to Superior Court (MS 1724) if not satisfied with the hearing decision.

A. General

Eligibility hearings are heard by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH). The hearings are held at 1400 West Washington in Phoenix, Arizona. Do not contact OAH directly unless you are asked to do so. Customers or their representatives may contact OAH at (602) 542-9826 or toll free at (877) 203-0226 if they have any questions or concerns. You may also direct a customer to the OAH website at www.azoah.com.

B. Office of Administrative Hearings (OAH)

OAH:

• Appoints an Administrative Law Judge (ALJ) to conduct the hearing. Any party may file a motion to disqualify an ALJ for bias, prejudice, personal interest or lack of technical expertise necessary for a hearing;

• Sets the date for the hearing in conjunction with the Office of Administrative Legal Services (OALS);

• Provides an interpreter if the complainant requests one; and

• Provides reasonable accommodation for special needs.

C. Administrative Law Judge (ALJ)

The ALJ:

• Presides over the hearing;

• Considers motions filed in writing by AHCCCS or the complainant such as a motion to:

¡     Consolidate two or more hearing requests;

¡     Continue the hearing (schedule the hearing at a later date);

¡     Expedite the hearing (set an earlier date for the hearing);

¡     Vacate (stop) a hearing;

¡     Hold a pre-hearing conference as defined in A.A.C. R2-19-112;

¡     Quash (suppress) a subpoena;

¡     Attend a hearing by telephone; or

¡     Reconsider a previous order;

• Orders depositions or issues subpoenas to compel the attendance of witnesses and the production of documents when a party shows a reasonable need for the information;

• Presides over a pre-hearing conference if scheduled;

• Administers oaths and affirmations to witnesses;

Excludes evidence if its value is outweighed by the danger of unfair prejudice, by confusion of the issues or by considerations of undue delay, waste of time or needless delay, or needless presentation of evidence.

• Exercises reasonable control over the manner and order of cross-examining witnesses and presenting evidence to get to the truth, and to avoid needless use of time and protect witnesses from harassment or undue embarrassment

• Bases his/her decision solely on the evidence presented at hearing; and

• Issues to the Director of AHCCCS a written recommended decision within 20 days from the conclusion of the hearing.

A. General

The AHCCCS Office of Administrative Legal Services (OALS) provides legal assistance to Program Support and processes hearing requests.

B.Responsibilities

When a hearing request is received, the Office of Administrative Legal Services:

• Determines if the hearing request was received timely. If not, OALS notifies the complainant in writing that the hearing request was received untimely and therefore, will not be scheduled for a hearing;

• Determines if the hearing request is the result of an adverse eligibility action for which the customer has the right to a hearing (MS 1113). If not, OALS notifies the complainant in writing that the matter cannot be appealed and copies the Eligibility Hearing Coordinator in Program Support;

• Denies the request for hearing if the individual who submitted the appeal is not authorized to request a hearing;

• Creates a case file;

• Assigns a "Matter Number" to the file;

• Notifies Program Support that a request for hearing has been received, and subsequently direct all correspondence related to the hearing to the Eligibility Hearing Coordinator in Program Support;

• Secures a hearing date from OAH and schedules the hearing;

Note: When the issue being appealed is the Community Spouse Income Allowance (CSMIA) or the Community Spouse Resource Deduction (CSRD), the hearing must be scheduled within 30 days from the date of the hearing request.

• Sends the notice of hearing to the complainant and the Eligibility Hearing Coordinator in Program Support;

• Accepts petitions for rehearing and review; and

• Issues the Director's Decision as the Director's designee.

A. General

The Eligibility Hearing Coordinator in Program Support is responsible for assisting the eligibility office with the hearing process.

B. Responsibilities

The Eligibility Hearing Coordinator:

• Maintains the DMS Hearing Calendar in the Public Folder;

• Monitors the DMS Hearing Calendar to ensure sufficient time is allowed;

• Receives, copies and timely distributes hearing packets and related documents;

• Prepares and distributes a weekly schedule of hearings to the eligibility offices;

• Reviews and evaluates the action that is being appealed;

• Assists eligibility staff in preparing for the Pre-Hearing Discussion;

• Assists eligibility staff in preparing for the actual hearing;

• Researches Federal and State law and rules to ensure the most appropriate authorities are included in the hearing packet;

• Identifies complex matters which will need an attorney and seeks assistance from OALS.

• Prepares motions as necessary (for voluntary withdrawals, continuances, etc.);

• Ensures that copies of all correspondence and evidence are provided to all appropriate participants in the hearing, including the eligibility office, OALS and OAH;

• Assists eligibility staff in presenting the Administration's case at the hearing; and

• Prepares petitions for rehearing or review if necessary.

A. General

The Eligibility Office is responsible for processing requests for eligibility hearings that it receives. When the Eligibility Office receives a request for hearing, the office must determine if the aggrieved action is due to financial or medical eligibility reasons.

B. Financial Hearings

When the Eligibility Office receives or is informed of a financial eligibility hearing request, the Financial Eligibility Specialist or other assigned staff:

• Enters the hearing request in the office's hearing database;

• Reviews the hearing request to determine if the hearing is necessary. 

• Neither encourages nor discourages the complainant to proceed with a hearing;

• Explains the hearing rights to the complainant (Hearing Rights Information form, DE-154);

• If eligibility has been discontinued and benefits will not be continued, advises the complainant of the right to reapply;

• Obtains a signed Authorization to Represent at Hearing (DE-169) form if the complainant wants someone other than the authorized representative to represent him or her at the hearing;

• Indicates on the Pre-Hearing Summary (DE-127) form or otherwise notifies the Program Support Eligibility Hearing Coordinator when the complainant is represented by an attorney or when the contested issue is complex and help is needed;

• Directs the complainant to OAH when the complainant requests an interpreter;

• Documents the case record;

• Continues eligibility (MS 1714), restores the share of cost amount (MS 1715) or restores the covered service to the prior level (MS 1716) when appropriate;

• Prepares and submits the hearing packet (MS 1717);

• Prepares a request for telephonic appearance if Eligibility Specialist is outside Metro area and includes the request in the hearing packet;

• Prepares for and attends the Pre-Hearing Discussion (MS 1718);

• Promptly forwards new information related to the hearing, including a summary of the result of the Pre-Hearing Discussion or a voluntary withdrawal, to the Eligibility Hearing Coordinator in Program Support;

• Prepares for, attends, testifies and presents evidence at the eligibility hearing (MS 1721), if one is held;

• Follows through on a written order issued by the ALJ; and

• Completes appropriate follow-up actions (MS 1722) when an eligibility hearing decision is received.

C. Medical Hearings

When the Eligibility Office receives or is informed of a medical eligibility hearing request, both the Financial Eligibility Specialist and the Medical Eligibility Specialist complete a part of the process.

• The Financial Eligibility Specialist who took the action or other assigned staff:

¡  Enters the hearing request in the office's hearing database.

¡  If the request for hearing was received by OALS and the medical determination was made in a different office, Program Support will send a request for hearing packet to both offices and the Financial Eligibility Specialist will complete a minimum packet and only completes the top portion of the Pre-Hearing Summary (DE-127) form including legal citations. The Medical Eligibility Specialist will complete a maximum packet;

¡  If the request for hearing was received in the eligibility office and the medical determination was made in a different office, the eligibility office hearing coordinator will fax the hearing request to the other office. The Financial Eligibility Specialist will complete a minimum packet and only completes the top portion of the Pre-Hearing Summary (DE-127) form including legal citations. The Medical Eligibility Specialist will complete a maximum packet;

¡  If the Medical and Financial determination were made in the same office, immediately forwards the minimum packet to the Medical Eligibility Specialist who completed the medical assessment.

• The Medical Eligibility Specialist:

¡   Reviews the hearing request to determine if the hearing is necessary;

¡   Neither encourages nor discourages the complainant to proceed with a hearing;

¡   Explains the hearing rights to the complainant (Hearing Rights Information form, DE-154);

¡   Obtains a signed Authorization to Represent at Hearing (DE-169) form if the complainant wants someone other than the authorized representative to represent him or her at the hearing;

¡   Indicates on the Pre-Hearing Summary (DE-127) form or otherwise notifies the Program Support Eligibility Hearing Coordinator when the complainant is represented by an attorney or when the contested issue is complex and help is needed;

¡   Directs the complainant to OAH when the complainant requests an interpreter;

¡   Documents the case record;

¡   Prepares and submits the hearing packet (MS 1717);

¡   Prepares a request for telephonic appearance if the Eligibility Specialist is outside Metro area and includes the request in the hearing packet;

¡   Prepares for and attends the Pre-Hearing Discussion (MS 1718);

¡   Promptly forwards new information related to the hearing, including a summary of the result of the Pre-Hearing Discussion or a voluntary withdrawal, to the Eligibility Hearing Coordinator in Program Support;

¡   Keeps the Physician Review Coordinator informed;

¡   Prepares for, attends, testifies and presents evidence at the eligibility hearing (MS 1721), if one is held;

¡   Follows through on a written order issued by the ALJ; and

¡   Completes appropriate follow-up actions (MS 1722) when an eligibility hearing decision is received.

D. Eligibility Office Hearing Log

Maintain a log documenting the date on which all requests for hearings are received.

A. Who Can Request a Hearing?

Any person may request a hearing. If you receive a hearing request from someone who is not the customer or an authorized representative, contact the customer.

IF the customer. . .

THEN. . .

Wants this individual to represent him/her at the hearing

• Send the Authorization to Represent at Hearing (DE-169) form to the customer with a Pending Notice DE-503 allowing 10 days to return the form.

• If you receive the signed Authorization to Represent at Hearing (DE-169) form before the hearing packet is due, send it with the hearing packet. Program Support will forward it to OALS.

• If you receive the signed Authorization to Represent at Hearing (DE-169) form after you sent the hearing packet, send it to Program Support immediately. Program Support will forward it to OALS.

• If the Authorization to Represent at Hearing (DE-169) form is not included in the hearing packet, OALS notifies the individual, in writing, that documentation must be submitted within ten days of the notice confirming that the individual filing the request for hearing is an appropriate authorized representative. OALS closes the case if the required documentation is not received within the given timeframe.

Does not want this individual to represent him/her at the hearing

• Complete a minimum hearing packet and

• Forward it to Program Support.

• Indicate on the Pre-Hearing Summary (DE-127) form that the person requesting the hearing is not authorized.

B. How a Hearing is Requested

A customer may request a hearing by:

• Completing and submitting the request for hearing section found on the back of the Notice of Action;

• Submitting a written request that contains at least the complainant's name, the eligibility action on which the hearing request is based, and the reason for the hearing request; or

• Calling the eligibility office and requesting a hearing, and then following up by submitting a written request (MS 1710.C).

A. General

The customer may submit a request for hearing by mail, fax, phone, or in person at either the Eligibility Office or the Office of Administrative Legal Services. 

The customer must make a request for hearing in writing to be a valid request.

B. Request Date

Date stamp all hearing requests upon receipt. Listed below is a chart to assist you in determining the hearing receipt date.

IF the request for hearing is. . .

THEN the date of request is the date. . .

Received by mail

Received by the Eligibility Office or OALS.

Received by fax

Of the fax transmission.

Note: If OALS receives the hearing request by fax and the request is subsequently faxed to Program Support and the Eligibility Office, the date OALS received the request is the request date.

Submitted in person

The request is submitted to the eligibility office or OALS.

Received by telephone

See below.

C. Request Date for Telephone Requests

If the customer telephones the eligibility office and requests a hearing follow the steps below:

Step

Action

1

Document the customer's name, telephone number, current address, the date and time of the call, and the reason the customer wants a hearing.

2

Explain the time deadlines for requesting a hearing and for receiving continued benefits, if appropriate.

3

Ask the customer if the customer has the notice of action for which the hearing is requested.

IF. . .

THEN. . .

Yes

Ask the customer to complete the hearing request section and mail, fax, or bring it to the eligibility office.

No

Send the customer a Reverse Side of Notice DE-500A or tell the customer the information that needs to be included on a hearing request.

4

Send a Pending Notice DE-503 with a due date of 10 days.

5

Determine the hearing request date.